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Case:Jock
Jocularity Dx 25 Aug 2004. Age 9.5 Tightly regulated on 0.5-0.9U bid Levemir (detemir) (First feline Levemir Patient). Neuropathy cured. No Ketones. Free-feeds on Felix in Jelly and similar, 6% cals from carbs. Other problems: Asthma. Slightly overweight. Intro Jocularity (born April 1996) is a rare Sphynx (Canadian Hairless) cat. He's a retired showcat. (Ever wonder where they go?) He was a Champion in Toronto in April 1997, (see his page http://romlin.com/jock/thekids.html) and he's been diabetic since August 2004. Jock's real name is "Champion Apaws Jocularity of Shaineh". He was always thin and athletic, though in the past couple years his weight crept up a bit, he was still the thinnest of the three. We sure were surprised to see him drop half his weight before our eyes and start drinking constantly, you know the story. Just to share Jock's own experience, I think everyone can benefit from skipping a lot of the wrong moves we made. Jock was diagnosed in August 2004 with diabetes, and prescribed Glipizide and no food recommendations in particular. He was eating Hill's Science Diet Light, and the vets didn't see any problem with that. These were all disastrous choices. These vets also suggested we check glucose but only with urine testing stix. Also a bad idea. Second vet It took us over 2 months to realize that Glipizide (most common diabetes pill) wasn't working (we didn't know about the pancreatic damage issue then) and by then Jock was skeletal, (50% of previous body weight) dehydrated, and, when brought into a better vet's office, not moving. He might have had DKA; we think so because he had ketone breath. This vet was able to save him (actually, fluids and insulin and he was perky the next morning) and he had some experience with Feline Diabetes. But not nearly enough. He was good enough to recommend on Dec. 20 2004 that we home test for blood glucose, and better still, he suggested that we go online and recommended some web sites for us. (Not the Feline Diabetes Message boardFeline Diabetes Message Board, unfortunately, but we did find it eventually.) He was a semi-good vet. He prescribed Humulin N insulin (a poor choice!), and a diet of "either Hill's M/D or W/D dry" (M/D is inadequate, W/D is awful). When we told him we were already feeding Hills SDL, he said that would do fine. (Very Wrong!) Switched to Levemir Feb 20, 2005 We were massively overdosing, over 11 units bid at one point, on Novolin N ("Insulatard" in Europe) After about 2 months (and 2 hypo events, one hospitalized!) we realized on our own that we needed a longer-acting insulin and insisted on it (we chose Levemir, and it turned out that we were the first ones, worldwide, using it on a cat.). Here's what happened when we switched to the longer, smoother Levemir: to Levemir ]] Sometime in February we found Sugarcats.com (thanks to our vet) and later, the FDMB the Feline Diabetes Message Board and started reading, and things started coming together. I started the wikipedia:Diabetes in cats and dogs page Mar 4 as a scratchpad for trying to understand everything at once. (The usual method on wikipedia is to post what you know and expect more knowledgeable folks to fix and expand.) We then started posting to the FDMB hoping to learn more, on March 9. The eureka moment was when we realized that the vet was capable of being wrong. (Thanks to the good folks at the FDMB!) Within a short time we had dropped the dry food and changed to a low-carb canned diet. At that point (Mar 10) our dosage dropped (over one weekend) from 6.5 units BID Levemir to 2.5 units. Then we started zeroing in on a regulation plan for Jock. By mid-may he was regulated ( always below 300 ) and 10 days after that we had him tightly regulated ( always below 180 ). 1 year after diagnosis, Jock is now happy, playing, leaping to the top of 6-foot structures, symptom-free, and as healthy as a cat can get, except a bit overweight. His insulin dose keeps slowly decreasing. I still suspect that if we'd got to the right advice in the first month, and skipped the months on Glipizide and crap food, we could have him in remission by now. The first 7 months of flailing and endangering Jock's health and life were totally unnecessary and I hope you can skip them and go straight to the good part. Regulation The good parts start here: Mar 10, 2005 The latest news is that Levemir has a smooth and slow curve on Jock, but his own BG reading variations appear to dominate those from the insulin. He's staying nicely within a range of 13-21mmol, but that's still too high, and his dosage is 6.5u BID! And the changes from 5, to 6, to 6.5, appeared to have no effect on his highs and lows. This is so puzzling that we're changing his diet instead of raising his insulin further. He's going on the Catkins diet this week, thanks to Dr. Lisa and Dr. Greco:Catkins Diet. Update March 18: A week later, a change to canned food (Whiskas, at carbs rating 22), has made a dramatic change to Jock's variations -- he's now between 15 and 16.7, and his numbers are flat as an ironing board! He's at a sharply reduced dose of 4u BID, and just moved up to 5u BID, in an attempt to bring him down into the 10-12 range. (180-216 in US). Dr. Lisa recommends trying to lower his carb intake further instead of adding insulin, and that would be best, I agree. Some kitten foods have carb ratings of only 3/100g. We've found the local brand MJAU, here's Janet & Binky's analysis: In 100 grams: Protein 10.5 grams * 3.5 = 36.75 Fat 5 grams * 8.5 = 42.5 Carbs .3 grams * 3.5 = 1.05 Total Calories: 80.3 % from protein: 36.75/80.3 = 45.8% % from fat: 42.5 / 80.3 = 52.9% % from carbs: 1.05 / 80.3 = 1.3% Extra stuff: Water 82 g Ash 1.7 g Fiber .5 grams Total 100 grams -- Janet Retrospective April 1: (added later to fill in the record) Jock's numbers are getting nicer, though still not quite predictable. We're still experimenting with different doses. His numbers range from 150 to 350, but not on any regular curve. We started Methylcobalamin, 5mg tablet once a day, today, and he really needs something for his legs, which are too weak for him to stand on. April 26 Latest update -- Jock's preshots are all around 15 (270 to 360) now and we're so happy! He's acting quite normal now, and the neuropathy, while still there, is definitely improving with the methylcobalamin. His current insulin dose is exactly 2U BID, and we'll have a curve to show you all shortly. Once we have a curve under 300 all day, with both endpoints about the same, we'll announce that he's regulated! Detemir/Levemir rocks! If you can't get it in the US yet, just wait till you can (The FDA approved it "conditionally" in 2003, so it's just a matter of letting the wheels grind) Jock is also a bit asthmatic, as I mentioned on the community board. The vets have told us it's not bad enough to treat, and they reccommend leaving him be, and that's what we're doing right now. Since the usual "best" treatment I've found (reading the feline asthma support groups) is inhaled steroids, I think we'll pass on that until the diabetes is definitively under control. May 14: Officially regulated on 3.0U levemir bid and low-carb (Felix) food. Preshots generally around 240, ranging from 180 to 280. May 18: Jock's neuropathy is officially recovered! He jumped to the top of the six-foot cat tree today. I credit the Methylcobalamin at least as much as the regulation, since it started working visibly on the second day, (April 2) even though there wasn't much regulation until this week. Overlap May 24: After experimenting with a single SID dose one day and lots of side experiments for peak time and duration, doing lots of math, I came up with an overlap plan and dose for Jock, and as of today it's officially working. He's now Tightly Regulated, between 4 and 9 (72 and 162) always, with a much flatter curve (due to overlap). This is the curve that made it all clear: June 14:Thanks to those experiments we have Jock TIGHTLY REGULATED! Here are his preshots and spotchecks for a couple weeks: July 29 update: Jock's regulated and dose is slowly dropping. He was at 3.0U of levemir bid, then at 2.5, then 2.25, now 2.0, and his latest preshots are: July 23 8pm 5.8 (104) July 24 8am 4.7 ( 85) July 24 8pm 5.5 ( 99) July 25 8am 6.9 (124) (all worried the dose wasn't enough... but) July 25 8pm 5.6 (101) July 26 8am 5.3 (95) July 26 8pm 5.3 (95) July 27 8am 6.9 (124) Creeping up but gave normal dose (why creeping?) July 27 6pm 16.4!(295) Should have stopped him! Boosters + extra 1/4u. July 28 8am 4.1 (74) Stabilizing again, bit low from the 1/4u July 28 8pm 4.9 (88) Back in the groove July 29 8am 15.1 (277) What the ....? July 29 8pm 5.2 (93) Ok back again Aug 10 Jock's dose has dropped again, down to about 1.8U bid. But now it's very sensitive to variation. If we give a bit much (like 1.9), he has low preshots (under 5) and we have to wait to shoot. If we give a bit too little (like 1.75), his numbers rise into the high 200's by mid-day. We've discussed this with others and think that the lowering doses are more likely a reduction in insulin resistance, not a regeneration of the pancreas. August 31: Jock's dose keeps dropping slowly, and he's a bit less finicky about dosage. His current dose is about 1.3 units bid. He can handle up to 1.4 but goes too low and hangs low a bit too long. 1.5 caused a rebound today. Sept 10: Not much change from last time, really. He's been on Whiskas instead of his usual Felix (aka Pussi), because of a bad batch of food, and so his ideal dose seems to be about 1.4U instead of 1.3. Sometimes he stays around 5 to 6 (90 to 108) all day, other times he starts rising rapidly a couple of hours before shot time, and when we catch that, we shoot a booster of "N", depending how high he's gone. (he goes up as high as 18 (324) sometimes, but 1.5 units of "N" brings him back in line.) He hasn't lowered his dose lately, but that could be the change in food and/or the occasional high numbers that stop him from improving. Difficulties Sept 15: Since Sept 10, Jock's numbers have been creeping higher, and yesterday we tossed the old insulin cartridge (after over 10 weeks, nearly empty) and started a new one. We've continued to get very high BG (often 20 / 360 ), but we've seen occasional very low numbers too, so we're assuming the new insulin is stronger and he's rebounding. Adjusting dose downward, trying 1.0 today. Sept 25: We've got a new batch of Levemir to replace the other new batch. We changed our minds about the rebound and decided to try more insulin, but keep up the "N" boosters in the meantime to keep Jock safe. This has been successful! At first we shot "N" up to every 4 hours, while starting on a low (1.0U) dose of Levemir. We continued raising the Levemir dose by 0.2 units every day, while shooting smaller and less frequent boosters. For example, today his preshot was still a bit high, 14.7mmol (265), and his dose yesterday had been 2.0U BID so: Dose raised again to 2.2U, and a starting booster of 1U "N". +6 spotcheck gave 7.8 (140) so it's working pretty good, but a lot of that is still the booster, which lasts 8-10 hours too. Suspect he'll need 2.4 or 2.5 Levemir to drop the boosters, i.e. back to his original regulation dose. Oct 1: Still at 2.2 units and it's settling nicely. He seems to like this dose, and this morning rewarded us with a preshot of just 8.1 (146). Yesterday's was nearly as good. We'll stay here a few more days and then raise to 2.3 if needed to get him back into Tight Regulation numbers. Protocol How we regulate Jock now: It's not easy to find shooting strategies for tightly-regulated kitties on the internet, so Sabina suggested I make this one public for the record. Jock is happy to be tightly regulated, but since he started trying to make his own insulin just a bit, he's been much harder to predict. Instead of his previous 60-160 range, he's now up to 90-180 because of that unpredictability. First reaction, as I posted before, was to shoot at different times when necessary (somewhere between +11 and +16 as required.) We will still do that when necessary, but we've refined it a bit so it doesn't happen so often. Also, sometimes he goes high for no apparent reason, and the protocol handles that too. Here's the latest "protocol", some of it lifted from what I posted to Angela today in Health. I think some variation of it may be helpful to Lantus users too: First note: Levemir, in Jock, peaks at about 11 to 12 hours. We are shooting just after peak in all cases, so we are using maximum overlap. Consequently we see a pretty level day without much peak, between 5 and 10 (90 and 180 US) when all goes well. My "scale" with Jock on Levemir goes: * Check BG at PS minus 1 hour (in case he's used it up early). * If he's really high (over 180) shoot full dose right away. (see below for extras) * If not, check again at shot time. * At shot time, check BG. If he's higher than previous check, shoot full dose. * If he's the same or coming down, and below 180, wait 30-45 min and check again. * Repeat checks until you see an up-trend, then shoot full dose, as soon as he's above 90. * Otherwise wait a bit more. That covers all low PS cases. For high Preshots, we add a boosterdose of "N" to bring him down fast, assuming the Levemir will keep him there once it kicks in. We expect a preshot of about 6-10 (110-180). We add 1 unit of N for PS > 13 (234) , two units for PS > 16 ( 288 ) , three units if PS > 19 (342), and we haven't seen much higher than that fortunately! "N" peaks in 4 hours with Jock. As I mentioned before to Pawprints, we shoot N only around shot time to avoid its peak coinciding with Levemir's. Note there's no partial dose option for Levemir, they just make things go screwy at this point. I've regretted every single part-dose. Now he does have a long-term "scale", since the insulin tends to build up a bit over time. So he has two "full-dose" amounts, 2.5U and "Thin" 2.5U. If he seems to be hanging low too long or getting uncomfortably low preshots lately, I'll give the thin dose for a day or two. Otherwise he gets the normal one. Yes there's a difference! Dec 16, 2005: Just a note to say that Jock loses regulation when changing insulin vials, and has to be re-regulated gradually on the new vial. His dose is always somewhere near 2.0 units BID, but not always the same. Boosters of Insulatard help us figure out where he belongs and keep him at reasonable levels until we understand his new dose. Food change Changed to a new food because of Rorschach's bad stomach. Nina reminded us of MJAU when we'd stopped using it for a long time due to its very low carb content, and the unenthusiastic reception all 3 cats gave it. We went back to the store and found that they have a new "Bitar i gele" (chunks in jelly) beef flavour which the cats all liked, but was too hi-carb for Jock. (About 6% calories from carbs). We are currently successfully feeding all 3 cats with a half-and-half mixture of "Bitar i gele" and regular Chicken or Turkey MJAU, mushed together indistinguishably with a spoon. The result seems to please them, is only about 4% calories from carbs, and keeps Rorschach's stomach happy too. We have to mush them together or each cat will cherrypick the parts he likes, leaving an unbalanced diet for the others. Falling dose Dec 18-26: Something exciting is happening! Over the last 9 days, Jock has been reducing his dose rather drastically. Here's his log (in Int'l units.) Regular shot times (bold) are at 08:40 and 20:40. Boosters, where mentioned, are Novolin N: This curve from Christmas convinced us to lower even faster than before: Dec 27th: 0.5 was not quite enough, and by bedtime he was at 9.6 and rising. So he got a miniscule (<1/4U) booster of Novolin N and that held him until morning. In the morning he got 0.7U again and that seems to be just right. Spotcheck at 14:20 shows 7.5, right in the zone... Jan 5th 2006 Well, he inched back up to 1.0U and seems to want just a tad more lately. His preshots are either around 9 to 10 and steady on good days, or 13-15 and rising on bad days, and we can't figure out any reason why one happens rather than the other. Morning of Jan 6th we're trying 1U of a new Levemir vial on the chance the old one is wearing out. Rapid rises for no reason Feb 10th: Over the last 2 months, we've seen him show two distinct patterns, and we can't really predict which one he'll be on. : Either he stays low (between 4 and 9) the entire day and night on his regular dose (about 0.6 or 0.7U of Levemir bid) : Or somewhere around +6 he starts to rise rapidly, leaving him at about 16 or 18 at shot time. We asked Dr. Hodgkins about this; she thinks it is glycogenolysisglycogenolysis (liver-produced glycogen becoming glucose) due to his liver "panicking" at low (but not dangerously low) blood sugar levels. Her advice is to control his numbers better, between 3 and 8, instead of the 4 to 10 range we've been aiming for lately. She thinks his liver must become accustomed to the lower blood sugar so it won't panic any more. We are doing this (when we're home) by doing a test around +6 twice daily, and giving very small Novolin N boosters (about a quarter-unit) only if he has gone over 10.0 This is usually enough to keep his numbers below 10 for the rest of the cycle. We don't want to increase the Levemir dose because he can easily use that to remain below 4 all day and past the next shot time. We still don't shoot Levemir on preshots below 4.5. Feb 18 Further refinements: We're now testing at Preshot, +8, and Preshot. At +8 we can tell if he's going to be rising up to about 15 (270) and needs a booster, or not. If not, he generally stays under 7.0 (126) all the way to the next shot. If his +8 check is over 10.0 (180), he gets a booster of between 0 and 0.25 units as shown on the syringe, of Novolin N/Insulatard. (0 units as measured on the syringe is a bit more than 0, it's about 1/5 unit on our syringes.) Yes, the zero-unit booster is quite effective! Jock's becoming quite a low-dose kitty. He's going down noticeably every month in Levemir dose, and his Insulatard booster dosage goes down in proportion. Someday he's gotta just stop needing it, right? He was first regulated at 2.5U bid, (in May 2005) so this must be a good sign. Problem is with these low doses it's hard to be accurate, and he's very sensitive to inaccurate dosing. Too much or too little and he rides around 14 to 16 all day. A couple of days of that and he starts to need more insulin, which makes guessing even harder. We're becoming artists with that little syringe! And we had to stop using the Novopen Junior since a half-unit is just too much now. Mar 24 We tried something interesting around Mar 7 -- we noticed that, even with the boosters, Jock was having trouble staying in his Tight Regulation range (4.0 to 8.5), though he could often do it for 24 or 48 hours, he would always bounce back up eventually. We decided that since Levemir is so much smoother than Insulatard, maybe we could just try lots of smooth Levemir instead. So we've now been dosing Levemir only, no boosters, but 3 times a day, sometimes 2, sometimes 4. Basically the rule is: * Test at 07:30, (11:30), 15:30, (19:30), 23:30 (optional tests when dose is changing) * If he's below 4.5 (81) don't shoot * If he's over that, shoot his normal dose for that day (which slowly varies over time) * If he's over 8.5 (153), raise his normal dose by 0.1 or 0.2 units, and check again in 4 hours. * If he skips more than one shot, lower his normal dose by 0.1 or 0.2 units. The amazing thing is that this method is getting MUCH flatter curves, between 3.5 and 8.5 for days at a time. We haven't used boosters in 2 weeks and Jock doesn't miss them. Curve over a couple of weeks coming soon. His "normal dose" has gone from 0.5 up to 0.9 and back down to 0.4 over 2 weeks. It's currently 0.5. When he goes out of the range, it's much less dramatic -- up to 10.0, not 16.0 as he was doing before on the Levemir+booster plan. He has not dipped below 3.5 at all. First half of March: Second half of March: April 16 Jock makes a honeymoon attempt. After 6 weeks of tight regulation and a BID dose down to 0.2U, Jock tried to go it alone. The good news was, he definitely was able to bring his numbers down after eating. The bad news: It wasn't enough -- He still needs insulin. The worse news -- he totally lost regulation for weeks after this attempt... Some details: http://www.felinediabetes.com/phorum5/read.php?8,311718,312386 June 11 Ok, we've been gradually bringing him back into line. After April 17 he needed more and more insulin until we caught up to him around May 15 at 1.5U BID. Since then we've been bringing him down back into range gradually, from 1.5 to 1.4, to 1.2 to 1.1. Just yesterday we lowered from 1.1 to 1.0. He's now at 1.0U BID again and here's today's curve, the first in a while: 08:30 PS 3.6 (64) (delay shot) 09:30 PS 4.7 (84) (shot 1U Levemir) 12:00 +2.5 3.8 (68) (about right for Levemir to start) 13:30 +4 4.2 (75) 15:00 +5.5 2.8 (50) (lower than expected, fed locarb) 17:00 +7.5 2.6 (46) (fed chicken wings) 18:30 +9 3.3 (59) (coming back up) 20:00 +10.5 5.0 (90) (and up) 20:40 +11 5.6 (101) (0.9U Levemir shot early to bring time back for tomorrow) ... 08:30 +12 6.6 (119) (looks like 0.9U was perfect last night.) Here's the graph: (Shot at 09:30 and 20:40) Comments: * Jock is riding rather low all day because 1.0U was actually a bit much for him. (it wasn't last week, so this is good news.) So tonight I lowered to 0.9U. * We shot again just after +11 because he was on his way up fast, and we want to shoot at 08:30 tomorrow, not 09:30. * If he follows his usual pattern, he will continue reducing dose for the next few weeks. Possibly culminating in another honeymoon attempt... July 1 We're now giving a small booster of "N" along with the Levemir shots, to keep the curves flatter. He's under good control mostly ( we've had two spikes, both apparently caused by NOT giving a little booster at shot time ). Dose gradually coming down again: * May: 1.5U BID + 0.3 to 0.5U "N" at shot time (booster size depends on preshot). * June: 1.0U BID + 0.2 to 0.4U "N" at shot time. * July: 0.7U BID + 0.1 to 0.3U "N" at shot time. The "N" booster is to smooth the transition from the old Levemir dose to the new one. The old one starts wearing off at around +11, and by +12 his BG is rising very fast, and accelerating (See chart Feb 10, above). The new Levemir dose takes about 3 hours to bring things back down to the preshot value (and that's if it can!) If BG's rise above about 8-9, the new Levemir dose may not be able to bring them back into range at all. So we avoid this by boosting at shot time. Curves for Levemir and Insulatard (Novolin N) Now that the Levemir seems to wear off more dramatically than before (as in Jan 7 curve), Jock's usual Levemir curve for 13 hours looks like this When you catch that one on the way up before it gets too high, the repeated curve looks like this: (with green bars=shots at 12 hour intervals:) Novolin N (Insulatard) peaks after about 4 hours, in a full dose in Jock: So we give a full dose of Levemir, combined with about a half dose of Novolin N. Here's what a half dose of Novolin N does: And here they are combined: So the Novolin N is taking effect just as he would be going high on the worn-out Levemir, and wearing off just after the Levemir kicks in. The resulting curve you can imagine, it's flattish around the preshot level for the first 5 hours, then flattish at the lower level Levemir prefers for the next 5 hours, then rising again. Basically what's shown at June 11 above. References Category:Feline casesCategory:Male casesCategory:Regulated cases Category:Oral med casesCategory:Humulin N cases Category:Levemir cases Category:Glucose toxicity cases Category:low-carb cases Category:Neuropathy cases Category:Other infection cases Category:Ketoacidosis cases Category:Booster cases Category:Tight Regulation casesCategory:Overlap casesCategory:Feline male casesCategory:Feline low-carb casesCategory:Feline regulated casesCategory:Feline tight regulation casesCategory:Feline ketoacidosis casesCategory:Feline neuropathy casesCategory:Feline other infection casesCategory:Feline booster users